Birth Defects Risk Factor Survey

NOTIFICATION: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us/ for more information.

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1. Which risk factor report(s) did you access?

Which risk factor report(s) did you access? 47,XXX

47,XYY

Achondroplasia

Anal Atresia

Atrial Septal Defect (ASD)

Conotruncal Heart Defects

Craniosynostosis

Diaphragmatic Hernia

Down Syndrome

Ear Defects

Esophageal Atresia

Gastroschisis

Holoprosencephaly

Hydrocephaly

Hypolastic Left Heart Syndrome

Intestinal Atresia/Stenosis

Klinefelter Syndrome

Neural Tube Defects

None

Omphalocele

Oral Clefts

Patent Ductus Arteriosus

Pyloric Stenosis

Renal Agenesis

Talipes Equinovarus (Clubfoot)

Triploidy

Trisomy 13

Trisomy 18

Turner Syndrome

Other (please specify)

2. Are there other birth defects that you would like to see a risk factor report for? If so, which?

Are there other birth defects that you would like to see a risk factor report for? If so, which?

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3. Please rate the risk factor series:

Disagree

Somewhat Agree

Strongly Agree.

It was at the appropriate reading level for me.

*Please rate the risk factor series: It was at the appropriate reading level for me. Disagree